SUBJECTIVE:Pt . is a .age G***P*** female who is here for gyn exam. .lmp . Pt uses *** for contraception. She is *** satisfied with this method. Her periods are ***regular every 28-30 days, lasting 4-5 days. Her bleeding is typically ***. Pt has *** prior h/o STDs. Pt *** do regular breast self exams. She has *** noted any abnormalities and has *** history of abnormal mammograms. She has *** history of abnormal Pap smears *** .
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.ros *** vaginal discharge, *** abdominal pain, *** dysuria
OBJECTIVE:.vs
General appearance: alert, in no distress
Skin: Skin color, texture, turgor normal. No rashes or lesions.
Breasts: inspection and palpation negative, no nipple discharge or bleeding
Abdomen: Abdomen soft, non-tender. BS normal. No masses, organomegaly
Pelvic: External genitalia & vagina normal. Bimanual exam revealed no adnexal masses or uterine enlargement.
Wet Prep: *** clue cells, *** yeast, *** trichomonads
Assessment/Plan:
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